First reported 3 Dec 2013•Latest report 14 May 2024
Definition
What this concern includes
Includes failures of the dedicated root cause analysis process, including initiation, investigator competence and training, evidence and stakeholder input, critical analysis, identification of lessons, action planning, completion and confirmation of resulting actions.
Not included
Excludes generic incident investigation or organisational-learning failures where root cause analysis is not the specifically identified process.
Excludes failures in implementing safety actions where no root cause analysis or root cause analysis action plan is involved.
Excludes generic clinician training deficiencies unrelated to undertaking root cause analysis.
Excludes deficiencies in the underlying clinical or operational process investigated when the root cause analysis process itself is not unsafe.
Reports
26
Distinct published reports
Individual concerns
27
A report can raise multiple concerns
Date range
2013–2024
First to latest report issue date
Stated actions
56
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
NHS England3
Royal Stoke University Hospital3
Cwm Taf Morgannwg University Local Health Board2
Department of Health and Social Care2
Devon Partnership NHS Trust2
Enteral (GB) UK2
International Organization for Standardization2
Nursing Times2
University Hospitals Sussex NHS Foundation Trust2
Axminster Medical Practice1
Black Country Healthcare NHS Foundation Trust1
Care UK1
Central and North West London NHS Foundation Trust1
Derriford Hospital1
Dudley Integrated Health and Care NHS Trust1
NHS trust18
Healthcare site7
Executive non-departmental public body3
Company2
Local health board2
Ministerial department2
Multi-service care provider2
Prison or young offender institution2
Standards body2
Independent healthcare provider1
Medicines and medical devices regulator1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
West Sussex
Concerns raised1
Failure of Root Cause Analysis investigations to identify care and service delivery problems
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Review processes for investigating perinatal deaths using RCOG and CQC best-practice models.
Stated by University Hospitals Sussex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2016.
Action
Obtain Trust governance-team support to make Serious Incident root-cause analyses rigorous and objective.
Stated by University Hospitals Sussex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2016.
Action
Implement the NHS England/Department of Health National Perinatal Mortality tool at the Trust when available from late 2017.
Stated by University Hospitals Sussex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 July 2016.
West Sussex
Concerns raised1
Failure to arrange a joint RCA of KMSS 111 and IC24 investigations
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Confirm a date with IC24 to share the Trust’s Serious Incident report findings.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 16 June 2016.
Action
Conduct a joint IC24–KMSS meeting to discuss cross-organisational learning and review the case.
Stated by Integrated Care 24Stated completedThe respondent said that this action was complete when they made their response on 16 June 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The Trust has no further control after an out-of-hours referral is passed between independent organisations unless another call is received.
Stated by South East Coast Ambulance Service NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
A further joint RCA is considered unnecessary because joint learning has occurred and existing/new processes and actions are expected to yield no new learning.
Stated by Integrated Care 24Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Stoke-on-Trent and North Staffordshire
Concerns raised1
Failure to escalate matters for comprehensive serious incident or root cause review
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Exeter and Greater Devon
Concerns raised1
Failure to implement the action plan arising from the Root Cause Analysis
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.10
Action
Provide comprehensive assessments and formulate recovery, care and risk plans for people using CRHT services.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 January 2015.
Action
Reassess CRHT patients before discharge when increased risks have been identified.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 January 2015.
Action
Record all telephone calls received by CRHT teams in clinical records.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 January 2015.
Action
Document discharge awareness and routinely consult and inform people and carers about CRHT discharge decisions.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 January 2015.
Action
Register both CRHT teams for the Triangle of Care initiative.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 January 2015.
Action
Contact people on the day they are discharged from CRHT, using face-to-face or telephone contact according to risk.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 January 2015.
Action
Increase OPMH consultant input and provide CRHT teams with direct access to OPMH consultants or named backup.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 January 2015.
Action
Have CRHT staff attend weekly Rougemont discharge-planning meetings to improve Adult/OPMH communication.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 January 2015.
Action
Develop recovery plans face to face with people using CRHT services whenever safe and practicable.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 January 2015.
Action
Consider the wishes and opinions of people receiving services in clinical decision making.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 January 2015.
Essex
Concerns raised1
Failure to conduct root cause analysis and develop lessons learned and an action plan
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner North London
Concerns raised1
Failure to share root cause analysis learning with relevant staff
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures of the dedicated root cause analysis process, including initiation, investigator competence and training, evidence and stakeholder input, critical analysis, identification of lessons, action planning, completion and confirmation of resulting actions.
